Provider Demographics
NPI:1710347034
Name:DERRICKSON, JODA P (PHD, RD, ACSM EP-C)
Entity type:Individual
Prefix:DR
First Name:JODA
Middle Name:P
Last Name:DERRICKSON
Suffix:
Gender:F
Credentials:PHD, RD, ACSM EP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:773 LAWELAWE ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96821-1700
Mailing Address - Country:US
Mailing Address - Phone:808-636-8830
Mailing Address - Fax:
Practice Address - Street 1:773 LAWELAWE ST
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96821-1700
Practice Address - Country:US
Practice Address - Phone:808-636-8830
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-29
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133VN1006X
HIMAT17219225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic